I move amendment No. 1:
To delete all words after "That" and substitute the following:
"Dáil Éireann
—welcomes and supports the Minister for Health's proposals for the development of a comprehensive, integrated health care system as set out in the national health strategy, Shaping a Healthier Future,
—commends the proposals contained in the strategy regarding the development of a plan for women's health, including the proposal, in relation to screening for breast cancer, that a decision would be taken on the question of setting up a national screening service as soon as the findings of the present study at the Mater Hospital Foundation have been evaluated and
—commends the Minister for the action taken and proposed in relation to the identification, counselling and treatment of women and their families who have tested positive for hepatitis C arising from the national screening programme."
I will deal later with the specific issues raised in the motion and by Deputies on the other side of the House. Any discussion on the health services should now be placed firmly in the context of the comprehensive and integrated strategy on health services which I published last week. This strategy will guide the development and improvement of all health services. I welcome the opportunity to outline for the House the main principle and directions embodied in the strategy, so soon after its publication. The House will see that the strategy gives priority for the first time to the development of a comprehensive plan for women's health.
The publication of the health strategy discharges an important committment of my Department under the Programme for Competitiveness and Work. It is the culmination of a root and branch examination of all aspects of the health services to which I have devoted the last 16 months since becoming Minister. This examination has revealed a service with very many strengths, but one which cannot deliver on its full potential because of organisational and other difficulties. Foremost among its strengths is the quality and commitment of its staff. Another important asset, the extent of which is perhaps unique to Ireland, is the involvement of the voluntary sector as a substantial and integral part of the public services. There is a real enthusiasm within the services for development and change, for progress and improvement.
The principal weakness is a lack of clarity about the overall focus or direction of the health services. In the absence of specific goals or targets, it is very difficult to assess real effectiveness. This position is unsustainable in a service which spends more than £2.25 billion of taxpayers' money each year and which could spend very much more on undoubtedly worthwhile developments if the resources were available. Notwithstanding the rhetoric engaged in by the Deputies opposite in calling for significant expenditure cuts, I am sure that like me they could name many projects which would be worthy of funding.
A second weakness, and one which has long been recognised, is the inadequate development of community services and of appropriate linkages between community and hospital services. This works against the objective of providing appropriate care in the most appropriate setting. It is clear that the organisational and management structures of the health services need to be significantly updated if real progress is to be made in tackling the other weaknesses I have identified.
When I became Minister for Health I was determined that I would build on the existing strengths of the services and implement the reforms needed to overcome the weaknesses. Just over a year ago I announced that with the assistance of my Department I would draw up a comprehensive national health strategy. I said that the strategy would have a clearly stated philosophy and clear and unequivocal objectives and targets and would provide for the necessary legislative measures to back them up.
The document published last week delivers fully on this commitment and has the potential to transform our health services for many years to come. The title of the document "Shaping a Healthier Future" conveys its main theme — the reshaping of the health services in terms of a clear, strategic direction so that improving people's health and quality of life becomes the primary and unifying focus of all our efforts.
Three important principles underpin the entire strategy — equity, quality of service and accountability. The Government's commitment to social justice has been seen in a wide range of policies since we took office and is reflected in the commitments to further progress which we have included in our Programme for a Partnership Government and the Programme for Competitiveness and Work.
There are few areas of Government policy which can have a greater impact on social justice than health policy. I am particularly pleased that in endorsing the health strategy my colleagues in Government have agreed in the clearest statement yet that our health services should first and foremost help those whose health needs are greatest. It is now an established fact that factors such as unemployment and poverty are linked with poor health status. We have also known for some time that certain groups, such as travellers, particularly women travellers, have health status far below that of the population as a whole.
The strategy contains a number of measures which will address this inequality, the most innovative of which is the creation of health development sectors. This means that each health board will be required to identify within its region those sectors which need special attention in terms of targeting health services. These sectors may be geographic areas or specific population groups, such as travellers or single mothers. The strategy explains how the health services will focus particularly on improving the health status and quality of life of these sectors.
The second principle is the measurement of quality. This has several dimensions. The formal measurement of the technical quality of the services will become an essential, integral part of their provision and all health care professionals will be expected to become involved in an ongoing clinical audit of their own areas.
However, there are other aspects of quality which can have a marked effect on a patient's satisfaction or otherwise with the service provided — Members opposite touched on these in their earlier contributions — aspects such as dealing efficiently, courteously and comprehensively with patients, showing sensitivity to their requirements. These aspects will also be evaluated through regular consumer or patient surveys.
The third principle is accountability. The strategy sets out new arrangements for improved legal and financial accountability. But it goes far beyond that — it sets out a new approach to the provision of health care under which everyone providing a service knows what is required of them and accepts responsibility for the achievement of agreed objectives.
This principle is especially important in the context of the necessary reorganisation of health structures. The strategy sets out the decisions the Government has made in relation to structures which will be followed by the necessary legislation.
The strategy document is in two parts. The first part is the strategy proper — five chapters explain how the system will be reshaped to bring about the necessary transformation in accordance with the principles which I have described. The second part is a four-year action plan which itemises the detail of what will be achieved in each individual service.
The objective and targets set out in the strategy and the action plan do not deal merely with service developments. They also deal with the importance of focusing our health promotion policies on tackling the main causes of illness and premature death. There are very significant potential reductions in the extent of illness and premature mortality if we can, as a community, adopt the appropriate preventive measures. A cohesive programme to bring this about is included in the strategy.
I intend this document to be the working agenda for everyone in the health services from today on. Its implementation will take account of the views and ideas which emerge in response to it. It contains an explicit invitation to all interested parties to consider and debate the strategy and its implications for all of us.
The strategy sets out broad principles and objectives, but these will have to be translated into detailed plans at national and at local level. I want to see the widest possible participation in this process.
In summary, the strategy is a landmark document which sets out objectives for the health services to achieve, structures to achieve them and mechanisms to measure progress. I am very encouraged by the extremely positive response it has received so far from a wide range of groups and commentators both within and without the health services. This augurs well for the task which now lies ahead — the reshaping and development of our services in order to overcome the weaknesses by building on its undoubted strengths.
I want to focus now on one specific section of the strategy, that dealing with women's health. I do not agree with the view expressed opposite that we should compartmentalise our health services, that we should look at women's health in isolation from everything else, or that we should look at one aspect of women's health only. That is why I spent so long working on a national policy. That is why I introduced my remarks this evening by focusing on that national policy.
The strategy identifies the need for a policy which is based on a comprehensive view of women and the issues that affect their health. At present, health services for women are organised by function. There is no framework to provide unified objectives or common approaches.
The strategy sets out the major elements which now underlie Government policy on women's health. These objectives include the following: to ensure that women's health needs are identified and planned for in a comprehensive way; to ensure that women receive the health and welfare services that they need at the right time and in a way that respects their dignity and individuality, with ease of access and continuity of care; to promote greater consultation with women about their health and welfare needs, at national, regional and local levels and to promote within the health services greater participation by women both in the more senior positions and at the representative levels.
I now want to turn to the issue of cancer and particularly breast cancer. I am determined that I will do everything I can, as Minister for Health, to reduce the incidence of cancer in Ireland. In the health strategy document which I recently launched I have set a medium-term target to reduce the death rate from cancer in the under-65 age group by 15 per cent in the next ten years. The strategy sets out a number of action programmes designed to achieve this target. The increasing number of deaths from lung cancer among women is an area of particular concern to me, the number not so much fewer than the number of deaths from breast cancer, which is frightening and worrying.
Increasing deaths among women from tobacco-induced disease reflects the great growth in smoking among women since the fifties. Smoking is a major causative factor in up to 90 per cent of deaths from lung cancer. Deaths from lung cancer have been increasing as a proportion of all cancer deaths among women. In Ireland, a total of 500 women died from lung cancer in 1992.
Over the last few years the health promotion unit of my Department has been particularly concerned with tackling the very worrying upward trend in the number of women smoking in this country. The unit has launched anti-smoking campaigns and other initiatives specifically targeted at women. The unit would be anxious to enlist the support of women's groups in its efforts in this area.
Despite the advances made in chemotherapy, radiotherapy and surgery which have revolutionised cancer care, cancer is an illness which retains its power to inspire fear and distress. Many cancer patients and those close to them, feel a sense of powerlessness in the face of this terrible illness. This is, perhaps, because of the severity of the symptoms associated with some cancers and its ability to spread and attack healthy tissue. As Minister for Health I am extremely conscious of this. I am very aware of the particular anxieties felt by women regarding breast cancer.
Increasing emphasis is being placed on early detection and the prevention of illness where possible. The European Union has made the fight against cancer and the value of prevention an integral part of its health policy. This initiative has developed in tandem with increased health awareness and health promotion in this country. Few of us now remain unaware of the links between diet, smoking and lifestyle with heart disease and cancer. Unfortunately, the causes are less clear in the case of breast cancer. Hereditary factors, diet, alcohol and late first pregnancies have all been mentioned as being possible among the influences which can increase the risk of breast cancer.
While mortality from breast cancer is not separately identified in published Eurostat data, World Health Organisation statistics based on age-standardised data indicate — and this is important — that breast cancer mortality rates are lower in Ireland than in the United Kingdom or Holland, the only two European Union countries that have national screening programmes.
In terms of establishing breast cancer incidence levels in Ireland, the new national cancer registry — which I opened in Cork in January — will enable us to provide accurate and comprehensive statistics on national incidence levels of breast cancer. In the meantime, we can avail of data on incidence levels from the southern tumour registry which is the most reliable database available in the country. In fact most countries do not have a national registry but rely instead on local registers such as the southern tumour registry.
The much publicised claim that Ireland has the highest incidence rate of breast cancer in Europe is misleading and inaccurate. In fact, using age-standardised data from the southern tumour registry. Ireland ranks fifth within the European Union in terms of incidence levels behind Holland, Luxembourg, Belgium and Denmark. I give this fact purely and safely for the sake of accuracy, not to underscore in any way the terrible seriousness of the problem.
As I mentioned earlier, unlike lung cancer, with its well documented links with smoking, the causes of breast cancer remain to be clearly established. Because it is not possible to say how breast cancer can be prevented, emphasis is placed on early detection at the pre-invasive stage, through mammography and consequent early treatment.
At present in Ireland mammography is used largely for symptomatic or worried women on referral by their general practitioner, consultant or through their local breast clinic. There are now diagnostic units at 17 hospitals throughout the country and expertise has been growing in all aspects of the early detection of breast cancer and its treatment.
Mammography screening involves the carrying out of mammography on a mass population basis. All Deputies who contributed said mammography was available to all those who want it. I agree with that statement. A national screening programme is quite different, it reaches out to all women, many of whom will never otherwise present themselves for screening. We have to work out mechanisms to have the most effective means of early detection.
It may be helpful to outline briefly some of the general principles which are considered necessary to underpin a successful screening programme. One of these is that the natural history of the disease should be well understood. Another is that there should be a suitable screening test and one which is acceptable to the population to be screened. Another essential factor in the success of such a screening programme is a high and consistent participation rate among the population to be screened. The absence of a national population register in Ireland makes the implementation of a national screening programme all the more difficult.
There is considerable debate and discussion internationally regarding the effectiveness of mammography screening programmes in reducing mortality from breast cancer. Our objective must be to reduce mortality rates.
The United Kingdom and the Netherlands are the only two EU countries which have organised national screening programmes specifically for women aged between 50 and 64 years. There is general agreement that mammography screening programmes are not effective in reducing mortality in younger women. Unfortunately, women aged over 65 have proved reluctant to come forward for screening.
Critics of mass population mammography screening programmes consider that not enough is known about the natural history of the disease and how it should be treated. Mammography is technically difficult to carry out and requires a high level of professional expertise.
Screening does not reach an absolute conclusion on the presence or absence of disease. It does not give a definitive yes or no but merely divides the screened women into test negatives or test positives for further investigation, if necessary. It is essential that the number of false negatives — I know the Deputy will appreciate this point — and false positives is kept to an absolute minimum, both to avoid unnecessary further investigation which can be traumatic for women and also to prevent women who test negative falsely from being lulled into a false sense of security. Standards of excellence in both the mammography equipment used and the staff carrying out the technique are therefore critical to its effectiveness. In a well organised mammographic screening programme, women must be invited to come for a mammogram at specific intervals. As I mentioned earlier, the test must also be acceptable to the population to be screened since a reluctance to come forward for screening or to accept an invitation to be screened will jeopardise the success of the programme.
Since the probability of developing breast cancer increases with age, screening needs to be repeated at regular intervals. The optimum interval between repeated screens has not yet been agreed by doctors. We must be aware of, and guard against, any potential hazards such as any danger associated with ionising radiation and unnecessary biopsy operations in women with false positive results.
Before proceeding with a national screening programme for women aged 50-64 years, it is imperative that the benefits to be derived from a well-organised screening programme are carefully and fully assessed. It is vital that expertise is gathered on how best to organise and manage a screening programme. For these reasons, my Department is supporting a major breast cancer screening programme currently underway at the Mater Foundation. This programme — the Eccles breast screening programme — is one of a network of pilot schemes which are at present underway in seven countries within the European Union. The other countries are Belgium, France, Spain, Portugal, Greece and Italy.
The Irish pilot programme covers a defined catchment area of north Dublin and Cavan-Monaghan. All women in the catchment area aged between 50 and 64 years are eligible to attend. Screening is provided free of charge. The Eccles programme has established itself as one of the leading European pilot programmes. The key factors in its success are common to all successful programmes, namely a centralised screening programme, having proper regard to quality assurance mechanisms, with strong clinical leadership and trained and dedicated radiological, epidemiological and radiographical support.
The Eccles breast screening programme is the first of its kind undertaken in Ireland. As indicated in the new health strategy — Shaping a Healthier Future — national policy to be followed in this area will be guided and influenced by the information we gain from this programme by the end of the year. My objective in breast screening is to put in place whatever mechanisms are required to reduce mortality from this terrible cancer.
I wish to deal with the action taken and proposed in relation to the identification, counselling and treatment of women and their families who have tested positive for hepatitis C arising from the Anti D immunoglobulin product. The Blood Transfusion Service Board informed me on 17 February 1994 that evidence had emerged that there was a possible link between the product Anti D immunoglobulin and heapatisis C. The board made arrangements to change the product and this took place on Friday, 18 February 1994. It has introduced a new virally inactivated product which has been supplied to all hospitals. I have already outlined publicly the importance of Anti D immunoglobulin and I say this in reference to Deputy Durkan's remark. This is a huge breakthrough for women to allow them to have babies. Many hundreds of children have come into this world because of the availability of Anti D. There are many women who if given the choice now would take the risk of Anti D in order to have a healthy child.
